Azlocillin/Aztreonam 209 Azlocillin Sodium (BANM, rINNM) Administration in hepatic or renal impairment. The in- although the incidence of cross-sensitivity appears to terval between doses of azlocillin may need to be increased to be low (but see below). Azlocilina sódica; Azlocilline Sodique; Azlocillinum Natricum; every 12 hours in moderate to severe renal impairment (creati- Azlocylina sodowa; Bay-e-6905; Natrii Azlocillinum. Sodium nine clearance less than 30 mL/minute); additional dosage re- Aztreonam should be used with caution in patients (6R)-6-[D-2-(2-oxoimidazolidine-1-carboxamido)-2-phenyla- ductions may be needed in patients with both severe renal and with renal or hepatic impairment. cetamido]penicillanate. hepatic impairment. Breast feeding. In a study in 12 healthy women given aztreon- Натрий Азлоциллин am, peak concentrations in breast milk were found to be less than C H N NaO S = 483.5. 1% of those in serum and this was considered suggestive of a low 20 22 5 6 1 CAS — 37091-65-9. risk of adverse effects in breast-fed infants. The American Aztreonam (BAN, USAN, rINN) Academy of Pediatrics states that no adverse effects have been ATC — J01CA09. seen in breast-fed infants whose mothers received aztreonam and ATC Vet — QJ01CA09. Atstreonaami; Azthreonam; Aztréonam; Aztreonamum; SQ- 2 26776. (Z)-2-{2-Aminothiazol-4-yl-[(2S,3S)-2-methyl-4-oxo-1- considers it to be usually compatible with breast feeding, al- though UK licensed product information recommends that Pharmacopoeias. In Pol. sulphoazetidin-3-ylcarbamoyl]methyleneamino-oxy}-2-methyl- mothers should refrain from breast feeding while receiving aztre- Incompatibility. Azlocillin sodium has been reported to be in- propionic acid. onam. compatible with aminoglycosides, ciprofloxacin, metronidazole, Азтреонам 1. Fleiss PM, et al. Aztreonam in human serum and breast milk. Br and tetracyclines. C13H17N5O8S2 = 435.4. J Clin Pharmacol 1985; 19: 509–11. CAS — 78110-38-0. 2. American Academy of Pediatrics. The transfer of drugs and oth- Adverse Effects and Precautions er chemicals into human milk. Pediatrics 2001; 108: 776–89. As for Carbenicillin Sodium, p.216. ATC — J01DF01. Correction. ibid.; 1029. Also available at: ATC Vet — QJ01DF01. http://aappolicy.aappublications.org/cgi/content/full/ Prolongation of bleeding time has been less frequent and less se- pediatrics%3b108/3/776 (accessed 25/05/04) vere with azlocillin than with carbenicillin. Hypersensitivity. Aztreonam is said to show little cross-reac- Hypouricaemia. Reports of transient asymptomatic decreases S O tivity with other beta lactams,1,2 but there have been isolated re- in serum-uric acid concentrations during treatment with azlocil- H CH3 ports of immediate hypersensitivity to aztreonam in patients with lin.1,2 a history of hypersensitivity to penicillin.3,4 H2N N N 1. Faris HM, Potts DW. Azlocillin and serum uric acid. Ann Intern H 1. Saxon A, et al. Lack of cross-reactivity between aztreonam, a Med 1983; 98: 414. N N monobactam antibiotic, and penicillin in penicillin-allergic sub- 2. Ernst JA, Sy ER. Effect of azlocillin on uric acid levels in serum. jects. J Infect Dis 1984; 149: 16–22. O O 2. Adkinson NF. Immunogenicity and cross-allergenicity of aztre- Antimicrob Agents Chemother 1983; 24: 609–10. SO3H onam. Am J Med 1990; 88 (suppl 3C): 12S–15S. 3. Alvarez JS, et al. Immediate hypersensitivity to aztreonam. Lan- Sodium content. Each g of azlocillin sodium contains about HOOC CH3 2.1 mmol of sodium. As azlocillin sodium has a lower sodium CH cet 1990; 335: 1094. 3 4. Hantson P, et al. Immediate hypersensitivity to aztreonam and content than carbenicillin sodium, hypernatraemia and hypoka- imipenem. BMJ 1991; 302: 294–5. laemia are less likely to occur. Pharmacopoeias. In Jpn and US, which allows the anhydrous or hydrated forms. Interactions Interactions USP 31 (Aztreonam). A white, odourless crystalline powder. As for Benzylpenicillin, p.214. Very slightly soluble in dehydrated alcohol; practically insoluble Caution is recommended in patients receiving aztreon- Antibacterials. For the effect of azlocillin on the clearance of in chloroform, in ethyl acetate, and in toluene; soluble in dimethyl- am and oral anticoagulants because of the possibility of cefotaxime, and a report of neurotoxicity, see p.228. For refer- formamide and in dimethyl sulfoxide; slightly soluble in methyl increased prothrombin time. ence to azlocillin affecting the disposition of ciprofloxacin, see alcohol. Store in airtight containers. p.246. Incompatibility and stability. Aztreonam has been reported Antimicrobial Action Antimicrobial Action to be incompatible with cefradine, metronidazole, nafcillin, and Aztreonam is bactericidal and acts similarly to the pen- Azlocillin has an antimicrobial action similar to that of piperacil- vancomycin. icillins by inhibiting synthesis of the bacterial cell wall; lin (p.315). Its activity in vitro against Enterobacteriaceae is gen- References. it has a high affinity for the penicillin-binding protein 3 erally less than that of mezlocillin or piperacillin, but it has com- 1. Bell RG, et al. Stability of intravenous admixtures of aztreonam (PBP-3) of Gram-negative bacteria. The activity of az- parable activity to piperacillin against Pseudomonas aeruginosa. and cefoxitin, gentamicin, metronidazole, or tobramycin. Am J Hosp Pharm 1986; 43: 1444–53. treonam is restricted to Gram-negative aerobic organ- Pharmacokinetics 2. Riley CM, Lipford LC. Interaction of aztreonam with nafcillin in isms, including beta-lactamase-producing strains, with intravenous admixtures. Am J Hosp Pharm 1986; 43: 2221–4. Azlocillin is not absorbed from the gastrointestinal tract to any poor or no activity against Gram-positive aerobes or significant extent. It has nonlinear dose-dependent pharmacoki- 3. Belliveau PP, et al. Stability of aztreonam and ampicillin sodi- um-sulbactam sodium in 0.9% sodium chloride injection. Am J anaerobic organisms. It is active against most Entero- netics. Doubling an intravenous dose results in more than double Hosp Pharm 1994; 51: 901–4. the plasma concentration. Between 20 and 46% of azlocillin in 4. Trissel LA, Martinez JF. Compatibility of aztreonam with select- bacteriaceae including Escherichia coli, Klebsiella, the circulation is bound to plasma proteins. The plasma half-life ed drugs during simulated Y-site administration. Am J Health- Proteus, Providencia, Salmonella, Serratia, Shigella, is usually about 1 hour, but is longer in neonates; in patients with Syst Pharm 1995; 52: 1086–90. and Yersinia spp. Some strains of Enterobacter and renal impairment half-lives of 2 to 6 hours have been reported. 5. Trissel LA, et al. Compatibility and stability of aztreonam and vancomycin hydrochloride. Am J Health-Syst Pharm 1995; 52: Citrobacter spp. are resistant. Aztreonam has some ac- Azlocillin is widely distributed in body tissues and fluids. It 2560–4. tivity against Pseudomonas aeruginosa, although most crosses the placenta into the fetal circulation and small amounts are distributed into breast milk. There is little diffusion into the strains of other Pseudomonas spp. are insensitive. Az- Adverse Effects treonam has good activity against Haemophilus influ- CSF except when the meninges are inflamed. The adverse effects of aztreonam are similar to those of enzae and Neisseria spp. Azlocillin is metabolised to a limited extent. About 50 to 70% of other beta lactams (see Benzylpenicillin, p.213, and a dose is excreted unchanged in the urine by glomerular filtration Synergy has been reported in vitro between aztreonam and tubular secretion within 24 hours of a dose, resulting in high Cefalotin, p.219). Hypersensitivity reactions, includ- ing skin rashes, urticaria, angioedema, exfoliative der- and aminoglycosides against Ps. aeruginosa and some urinary concentrations. Azlocillin is partly excreted in the bile Enterobacteriaceae. where it is also found in high concentrations. matitis, eosinophilia, bronchospasm, and rarely anaphy- Aztreonam is stable to hydrolysis by many beta-lacta- Plasma concentrations are enhanced if probenecid is given. laxis and toxic epidermal necrolysis, may occur in mases and appears to be a poor inducer of beta-lacta- Azlocillin is removed by haemodialysis. patients receiving aztreonam, although it has been re- ported to be only weakly immunogenic. Gastrointesti- mase production. Acquired resistance has occasionally Uses and Administration nal effects include diarrhoea, nausea, vomiting, mouth been reported. Azlocillin is a ureidopenicillin and, like piperacillin (p.316), is ulcer, and an abnormal taste. used mainly for the treatment of infections caused by Pseu- Pharmacokinetics domonas aeruginosa. It has been used particularly for septicae- Phlebitis or thrombophlebitis has been reported after Aztreonam is poorly absorbed from the gastrointesti- mia, and infections of the respiratory and urinary tracts, and also the intravenous use of aztreonam, and pain or swelling nal tract and is therefore given parenterally. Absorption for peritonitis; for details of these infections, see under Choice of after intramuscular injection. Antibacterial, p.162. after intramuscular injection is good; peak plasma con- Azlocillin is commonly used with an aminoglycoside; however, Use of aztreonam may result in the overgrowth of non- centrations of about 46 micrograms/mL have been they should be given separately as they have been shown to be susceptible organisms, including Gram-positive cocci. achieved within 1 hour of a 1-g dose. Aztreonam has a incompatible (see Incompatibility,